Hip osteotomy


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  • Fig. 7 — Schematic ( left ) and radiographic ( right ) presentations of coxa profunda (detailed view of anteroposterior pelvic radiograph) in 29-year-old woman. Acetabular fossa (F) is touching or overlapping ilioischial line (IIL). Femoral head (H) is more covered, resulting in decreased femoral head extrusion index (E / [A + E]), neutral acetabular index (AI'), and increased lateral center edge (LCE') angle. A' = covered portion of the femoral head, E' = uncovered portion of the femoral head. Fig. 6 — Schematic ( left ) and radiographic ( right ) appearances of normal hip (detailed view of anteroposterior pelvic radiograph) in 35-year-old man. Acetabular fossa (F) is lateral to ilioischial line (IIL). Acetabular index (AI) is positive, and femoral head (H) is not entirely covered by acetabulum (E). Projected anterior wall (AW) lies medially to posterior wall (PW), which typically runs more or less through center of femoral head. Extrusion index (E / [A + E]) is approximately 25%. Lateral center edge (LCE) angle is 25–39°. Epiphyseal scar lies in femoral head circle ( arrows ). A = covered portion of femoral head, E = uncovered portion of femoral head.
  • Fig. 8 — Schematic ( left ) and radiographic ( right ) presentations of protrusio acetabuli (detailed view of anteroposterior pelvic radiograph) in 42-year-old woman. Femoral head line (H) is crossing ilioischial line (IIL). As a consequence, femoral head extrusion index (E / [A + E]) is zero or even negative, acetabular index (AI") is negative, and lateral center edge (LCE") angle increases. F = acetabular fossa. A" = covered portion of femoral head, E" = uncovered portion of femoral head.
  • Fig. 10 — Schematic ( left ) and radiographic ( right ) presentations of focal anterior overcoverage of hip in 29-year-old woman. Acetabular retroversion is defined as anterior wall (AW) being more lateral than posterior wall (PW), whereas in normal hip anterior wall lies more medially. This cranial acetabular retroversion can also be described by figure-8 configuration.
  • Fig. 11 — Schematic ( left ) and radiographic ( right ) presentations of too-prominent posterior wall (PW) show posterior wall line running laterally to femoral head center in 30-year-old man.
  • Fig. 2  Prominence of the femoral head-neck junction in the anterior/anterosuperior portion of the proximal femur ( white arrows ) is known as the pistol grip deformity due to its similarities with the smooth hand grip of many pistols
  • Hip osteotomy

    1. 1. Then Why am I delivering this lecture ?-Write an answer in the DNB/MS exam- Get a VERY BASIC understanding….- Stimulate further reading if you care
    3. 3.  Campbells 10 edition Tachdigian :Peadiatric Orthopaedics Mc nicoll :Hip Osteotomies Roger Dee: Prinicples & PracticeOrthopaedics AAOS: ICL Tronzo : Hip Surgery OCNA : Pediatric Hip Disorders
    4. 4. Hip with hope Vs Hip with out hope?
    5. 5. Hip with hope ?
    6. 6.  Biomechanics Asessment General Overview Specific aetiology FAI
    7. 7.  Hip designed to- support BW- permit mobility Max ROM 140 flex/ext, 75 add/abd Functional ROM 50-60 flex/ext 1.8-4.3 x BW through hip Highest ascending stairs
    8. 8.  One legged stance 5/6 BWon femoral head Ratio of lever arms to BW3:1
    9. 9.  Cane in Contralateralhand decreases JRF Long moment armmakes iteffective 15% BW to canereduces joint contactforces by 50%
    10. 10.  Dynamic analysis much more complex Forces across hip joint combination of:◦ Body weight◦ Ground reaction forces◦ Abductor muscle forces
    11. 11. Improvingabductorfunction willdecrease jointreactiveforces
    12. 12.  Physical exam to ensure ROM Plain films◦ Standing AP◦ Frog leg lateral◦ False profile (anterior lip cover.)◦ Full abduction/adduction CT scan +/- 3D reconstruction
    13. 13. True lateral view made with the patientstanding,the pelvis turned 25 degreestoward the beam the ipsilateral foot and knee &the radiographic film perpendicularto the beam
    14. 14.  Osteotomies improve hip function◦ Increasing contact area / congruency◦ Improve coverage of head◦ Moving normal articular cartilage into weight bearingzone◦ Restore biomechanical advantage / Decreasing jointreactive forces◦ ?? Stimulating cartilage repair
    15. 15.  Ostoeotomy can be viewed as either◦ Reconstructive◦ Salvage Femoral osteotomy to correct proximal femoralabnormalities and vice versa
    16. 16.  FemoralVarus,Valgus,Derotation,Ext,FlexNeck, Intertrochanteric,Sub troch PelvicRe orientationSalvage Combined
    17. 17. Goal of reconstructive osteotomy, femoral or pelvic are-Restore as nearly normal anatomy as possible-Return joint pressures and loading patterns to normalprimary problem is malalignmentGoal of salvage osteotomies are-Relieve pain and improve function enough to delay the THRin active patients <50
    18. 18.  Neuropathic arthropathy Inflammatory arthropathy Active infections Severe osteopenia Advanced arthritis/ankylosis Advanced age *smoking, obesity
    19. 19.  Intact lateral portionof femoral head isprerequisite Can be combined witheither flexion orextension component
    20. 20.  Indications: hip joint instability b/c femoraldeformity which corrects with internalrotation & abduction view Pelvic osteotomy should be performed in ptswith CEA < 15 degrees Useful some DDH, SCFE, LCP, AVN andfemoral neck non-union/malunion
    21. 21.  Potential to shorten limb Weaken abductors Trendelenburg gait Potential difficulty with stem insertion infuture arthroplasty
    22. 22.  Coxa vara Performed ifadduction filmreveals concentricreduction
    23. 23.  Moves non-inervatedinferior cervicalosteophytes into contactwith floor of acetabulum Lateral traction onsuperior capsule maystimulatefibrocartilagetransformation
    24. 24.  Reconstructive◦ Salter 18m – 6y◦ Pemberton 18m – 10y◦ Steel skeletal maturity◦ PAO (Ganz) skeletal maturity Salvage◦ Chiari skeletal maturity
    25. 25.  Single Innominate osteotomy Acetabulum together with ilium and pubisrotated Held by wedge of bone Illiopsoas & adductor tenotomies common 18 mon to 6 years
    26. 26.  Pericapsular osteotomy for residual dysplasia Hinges through the triradiate cartilage – must beopen!! Changes the volume & orientation of acetabulum Although good results up to 10 most recommend 6to 8 years
    27. 27.  Indication : DDH inolder child Need good ROM Secure with bonegraft & AO screwfixation
    28. 28.  Contraindications◦ Limited ROM◦ Incongrous reduction◦ Significant joint spacenarrowing / degenerativearthritis Two incision approach
    29. 29.  Devised by Ganz Indication –DDH in adolescents& adults Achievescontainment &congruency
    30. 30.  Permits extensive reorientation Preserves blood supply Posterior column remains intact – true pelvisunchanged Single incision Preferred reconstructive osteotomy foracetabular dysplasia
    31. 31.  Devised by Chiari 1950’s Salvage procedure Relief of pain in incongrous hip Increases coverage by medializing hip centre Fibrocartilage transformation of superiorcapsule
    32. 32.  Chiari reported 200 procedures◦ 2/3 good to excellent outcome◦ 1/3 improved Similar results by others While pain relief is predictable,trendelenburg gait remains Trochanteric advancement may alleviatetrendelenburg gait
    33. 33. •Hip Dysplasia•Legg-Calve-Perthes Disease•Slipped Capital Femoral Epiphysis•Post septic sequeale•TB Hip•Epi/met dysplasias
    34. 34.  Prevalence of OA by age 50◦ DDH 40-50%◦ LCP 50%◦ SCFE 20% Despite many recent advances arthroplasty hasmany limitations in younger patients
    35. 35.  Femoral:Varus+/- Shortening +/- Derotation PelvicSalters & ModificationsPembertonSteels Combined
    36. 36. Persistent dysplasia can be corrected byRedirectional proximal femoral osteotomy invery young children.If the primary dysplasia is acetabular, pelvicredirectional osteotomy alone is moreappropriate.Many older children require femoral and pelvicosteotomies.
    37. 37. Pre req for Pelvic osteotomy• Femoral head has been concentrically seated in thedysplastic acetabulum• the joint has failed to develop satisfactorily,• growth potential of the acetabulum no longer existsIf primary acetabular dysplasia then Pelvic osteotomyAge : 4 – 8 : Femoral , if persistent dysplasia then Pelvic added>8 yrs : pelvic + Femoral shorteningImportant to correct soft-tissue anomaly and bony deformity toprevent redislocation
    38. 38. DDHZadeh et al. 82 children (95 hips)  1.    Hip stable in neutral position—noosteotomy  2.    Hip stable in flexion and abduction—innominateosteotomy  3.    Hip stable in internal rotation and abduction—proximal femoralderotational varus osteotomy  4.    “Double-diameter” acetabulum with anterolateral deficiency—Pemberton-type osteotomy
    39. 39. Non Union Neck Femur
    40. 40. Pauwels Valgus with Fixation+/- Fibula/Vas Fibula/TFL MPG( Bakhis )/Quad Fem ( Meyers)Salvage: Mc MurraysArm Chair effectNot aiming at fracture unionBiological effectsMechanical effectsSchanz : PSO
    41. 41. Schanz
    42. 42.  Pelvic osteo: Chiari , Salter Proximal femur: SchanzPSO: Dec lurchInc Legth Trochanteric ArthroplastyColonasEl episcopos/Harmons Corrective osteotomy
    43. 43.  Stage 1Greater trochanter is placed into the acetabulumHip abductors are moved distally on the femur Stage 2A proximal femoral osteotomy 1 month later,+/- acetabuloplastyIdeal in children younger than 10 years
    44. 44.  Femoral : Shortening +/- VDRO Pelvic : Roomy acetabulum: Pembertons
    45. 45. Open Femoral: VEROClosed Pelvic: Salters innominate
    46. 46.  Valgus + ExtensionWorks if healthy bone can be reorientedunder wt bearing zone Sugiokas : Transtrochanteric reorientation
    47. 47. Sugioka Osteotomy
    48. 48.  Indications TypesLocation: Sub capital: Fish & DunnBase of neck( IA) : KramerExtra articular base: AbramsIntertrochateric : Southwick: ValIn Rot Flex O ComplicationsAVNChondrolysis
    49. 49.  Femoral: Valgus,Varus,=/- Ext , flex PelvicGanzSalters
    50. 50. Mullers principles:Advanced OA < 50 degrees of motion in flexion Not a good candidate forintertrochanteric osteotomy.RA : Poor progIntertrochanteric osteotomy in AVN effective only if healthy bone can bebrought into the weight bearing area.Extensive involvement and collapse of the femoral head arecontraindications.Osteotomy should increase and not decrease the weight bearing area ofthe femoral head.Fixed adduction deformity is CI to varus osteotomy and fixed abductiondeformity to valgus osteotomy.Stable internal fixation is important, permits early motion, and enhancesunion of the osteotomy.Recurrence of hip pain from arthritis may be simulated by bursitis over aprotruding internal fixation device.
    51. 51. If it fits better with the hip in abduction, an adduction (varus) osteotomyis appropriate.If the head fits better in the acetabulum with the hip in adduction, anabduction (valgus) osteotomy is appropriate.Early secondary arthritis of the hip -primary acetabular dysplasiaSmall center-edge angle leaves the lateral aspect of the articular surfaceof the femoral head uncoveredThis results in high stresses at the weight bearing portion of the articularsurfaces of the hip, leading to early degenerative changes
    52. 52. Varus osteotomy alone is indicated in-spherical femoral head,-little or no acetabular dysplasia (a center-edge angle of at least 15 to 20 )-signs of lateral overloading-valgus neck-shaft angle of more than 135 degrees-Medial displacement of the shaft by 10 – 15mmCentre the kneeRelax the abduc, adduc , flexIncrease the wt bearing area-Causes shortening-Trenedelenberg gait
    53. 53. Advantages of periacetabular osteotomy :(1) Only one approach is used(2) large amount of correction can be obtained in all directions(3) blood supply to the acetabulum is preserved(4) posterior column of the hemipelvis remains mechanically intact,immediate crutch walking with minimal internal fixation(5) the shape of the true pelvis is unaltered-normal delivery(6) it can be combined with trochanteric osteotomy if needed
    54. 54. Shelf Osteotomies Vs Chiari Osteotomy inAcetabular dysplasiaShelf osteotomy : Moderate dysplasia without severe arthrosis,Chiari osteotomy :Severe dysplasias, with or without arthrosis.
    55. 55.  Excellent results with Middle path regimen? Thomas test of recovery Pelvic suppport osteotomy(PSO)-Shanz Milch Bachelor Osteotomy:PSO+Girdlestone
    56. 56. Girdlestone Arthroplasty
    57. 57. •Coxa profunda – floor offossa acetabuli overlapsilioischial line medially•Pincer type FAI•Creates deep acetabulum•General overcoverage•Normal
    58. 58. •Protrusio acetabuli – occurs whenthe femoral head overlaps theilioischial line medially•Pincer type FAI•Creates deep acetabulum•General overcoverage•Normal
    59. 59. •Lateral center edge angle – pincer type FAI•Normal is between 25 and 39 degrees•Increases with deeper acetabulum and more overcoverageProtrusioacetabuli
    60. 60. •Acetabular retroversion – pincer type FAI•Cross over sign•Focal acetabular overcoverage•Cranial anterior wall line projects laterally•Anterior/anterolateral labrum is obstacle to flexion and internal rotation•Distinguish from deficient posterior wall
    61. 61. •Posterior wall sign – pincer type FAI•PW line should descend through center of femoral head•Medial – deficient•Lateral – prominent
    62. 62. •Pistol grip deformity - Cam type FAI•Loss of normal concavity•Etiology•Growth abnormality of the capital femoral epiphysis•SCFE•LCPD•Fracture healing
    63. 63. •Horizontal growth plate sign - Cam type FAI
    64. 64. •Some predisposing factors to FAI•Legg-Calve-Perthes disease•Congenital hip dysplasia•Slipped capital femoral ephiphysis•Avascular necrosis•Malunited fractures•Acetabular protrusion•Elliptical femoral head•Retroverted acetabulum•Prominent femoral head-neck junction•Proposed etiologies•Abnormal anatomy•Prominent femoral head neck junction•Acetabular overcoverage
    65. 65. •Middle to older aged women (40)•Seen in ballet dancers•Close approximation of acetabular rim and femoral neck –acetabular abnormality•Acetabular overcoverage•Focal articular damage•Acetabular damage can propagate•Primary radiographic signs•Coxa profunda•Protrusio acetabuli•Acetabular retroversion•Decreased extrusion index•Neutral acetabular index•Posterior wall sign•Posterior inferior cartilage abrasion due to contracoup injury
    66. 66. •Young males (32 years)•Primary femoral abnormality•Aspherical femoral head•Femoral head jams into acetabular rim•Shear forces on labrum and cartilage•Diffuse articular damage•Primary radiographic signs•Pistol grip deformity•CCD angle less than 125 degrees•Horizontal growth plate sign•Alpha angle greater than 50 degrees•Femoral head-neck offset less than 8 mm•Femoral retrotorsion